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Vol.
XXVI No. 37
September
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Twenty Five Years After Alma Ata
Amit Sen Gupta
THE
next year is going to be the 25 anniversary of the Alma Ata Declaration. The
Alma Ata Declaration of 1978 was seen at that time as a watershed in the
understanding regarding public health. The declaration, adopted by almost all
the countries of the world had asserted the necessity for the State to provide
accessible, affordable and comprehensive health care services to all the people.
Unfortunately, in the decades following the declaration, neo-liberal economics
supplanted this view across the globe. Within less than a decade of the adoption
of the declaration, the World Health Organisation proposed actions that
undermined the basic premise of the Alma Ata Declaration. Since then the WHO
itself has been superceded by the World Bank and the IMF as the key players in
formulation of policies in the health sector.
DECIMATION
OF HEALTH INFRASTRUCTURE
In
the last two decades the infamous Structural Adjustment Policies, thrust upon
developing nations by the IMF have decimated health care facilities in almost
all developing countries. Specifically, they had the following consequences for
the health sector:
i.
A cut in the welfare investment, leading to gradual dismantling of the public
health services.
ii.
Introduction of service charges in public
institutions, which has now made the services inaccessible to the poor.
iii.
Handing over the responsibility of health service to
the private sector and undermining the rationality of public health. The private
sector on the other hand focused only on curative care. India for instance, has
been forced to reduce its public health expenditure in health and to recover the
cost of health services from its users by international banks.
iv.
The voluntary sector, which has also stepped in to
provide health services is forced to concentrate and prioritise only those areas
where international aid is made available – like AIDS, population control, etc.
These
“fundamentals” were more sharply focused upon in 1987 by the World
Bank document titled “Financing Health Services in Developing
countries” The document recommended that developing countries should:
1)
Increase amounts paid by patients.
2)
Develop private health insurance mechanisms (this requires dismantling of state
supported health services as if free or low cost health care is available there
is little interest in private insurance).
3)
Expand the participation of the private sector.
4)
Decentralise government health care services (not real decentralisation but an
euphemism for “rolling back” of state responsibility and passing on
the burden to local communities).
These
recommendations were further “fine-tuned” and reiterated by the Bank’s
World Development Report, 1993 titled “Investing in Health”.
This document represents the Bank’s major foray into health policy formulation.
Today the Bank is the decisive voice in this regard, and organisations such as
the WHO and UNICEF have been reduced to playing the role of “drum
beaters” of the Bank. As a Bank economist candidly reflected: “Policy
lending is where the bank really has power – I mean brute force. When countries
really have their backs against the wall, they can be pushed into reforming
things at a broad policy level (which) normally, in the context of projects,
they can’t. The health sector can be caught up in this issue of
conditionality”
WIDESPREAD
CONSEQUENCES
In
almost every developing country, these prescriptions have been avidly lapped up.
In Philippines health expenditure fell from 3.45 per cent of GDP in 1985 to 2
per cent in 1993; and in Mexico from 4.7 per cent of GDP to 2.7 per cent in the
decade of the 80s. Even developing countries with a strong tradition of
providing comprehensive welfare benefits to its people were not spared (with the
exception of Cuba). In China health expenditure is reported to have fallen to 1
per cent of GDP and 1.5 million TB cases are believed to have been left
untreated since the country introduced mechanisms for cost recovery. In Vietnam
the number of villages with clinics and maternity centres fell from 93.1 per
cent to 75 per cent.
These
prescriptions are a major contributory factor to the disruption of the rural
primary health care system in India. In GDP terms health expenditure in the
country (already one of the lowest in the world) has declined from 1.3 per cent
in 1990 to 0.9 per cent in 1999. While central budgetary allocation has remained
stagnant at 1.3 per cent of total outlay, the budgetary allocation to health in
state budgets (which account for over 70 per cent of total health care
expenditure of the country) has fallen in this period from 7.0 per cent to 5.5
per cent. This is a direct consequence of the squeeze imposed on the finances of
the states by the economic liberalisation policies. In reaction to this,
desperate state governments are queuing up in front of the World Bank to receive
Bank aided projects. This is proving even more disastrous as these projects
impose strict conditionalities like cost recovery.
MACROECONOMIC
COMMISSION ON HEALTH
The
World Health Organisation, long a silent spectator to the process whereby the
Bank had usurped its functions, attempted to make amends by setting up a
Commission on Macroeconomics and Health. The Commission’s Report was unveiled by
Gro Brundlandt in December 2001. The CMH has been touted as the WHO’s endeavour
to enage the best economic minds of the world in producing a vision paper on
health in a globalised world. Appropriately, the Commission was chaired by
Jeffrey Sachs, described by the New York Times as “probably the most
important economist in the world”. What we have before us, as a result of
this exercise, is an unabashed attempt by the WHO to speak the language of the
Bank. The ideological takeover of the WHO is, thus, complete.
The
Report in its introduction says, “With globalization on trial as never
before, the world must succeed in achieving its solemn commitments to reduce
poverty and improve health”. In other words, poverty reduction and health
improvement are goals that need to be achieved in order to rescue globalisation
from the dock!
While
this is not the place to go into a detailed critique of the Commission’s Report,
some features of the Report are worth discussing here. The Report in its Preface
says, “We have found that extending the coverage of crucial health
services, including a relatively small number of specific interventions, to the
world’s poor could save millions of lives each year, reduce poverty, spur
economic development, and promote global security.” Who has found this?
Where is the data that supports such a claim? The data actually indicates that,
to the contrary, technocentric top down interventions waste scarce resources.
But clearly, the report starts from the premise that Health can be broken down
to a few “magic bullets” appropriately delivered at a target. It is a
premise that is the exact opposite of the essential tenets of public health.
The
Report is also designed to set the ground rules for developing countries wanting
to access funds from donors (read rich developed countries). In an unabashed
defence of donor driven policies the Report says: “Where countries are not
willing to make a serious effort, though, or where funding is misused, prudence
and credibility require that large-scale funding should not be provided. Even
here, though, the record shows that donor assistance can do much to help, by
building local capacity and through the involvement of civil society and
NGOs”. The key message is clear: listen to donors, or else they will bypass
sovereign governments and target NGOs and private institutions to drive their
agenda through.
Possibly
the clinching message in the Report is: “the Commission recommends that
each developing country establish a temporary National Commission on
Macroeconomics and Health (NCMH),
. The National Commissions would work
together with the WHO and World Bank to prepare an epidemiological baseline,
quantified operational targets, and a medium-term financing plan”. Ask the
Bank what is good for you even though you know they have made a mess on earlier
ocassions!
The
Report’s signature tune is best summed up by its comments on the pharmaceutical
industry: “The corporate principles that have spurred recent and highly
laudable programmes of drug donations and price discounts need to be generalized
.Industry is ready, in our estimation, for such a commitment, enabling access
of the poor to essential medicines, both through differential pricing and
licensing their products to generics producers. ..
At the same time, it is
vital to ensure that increased access for the poor does not undermine the
stimulus to future innovation that derives from the system of intellectual
property rights”. While global opinion mounts against the pharmaceutical
industry, particularly their inhuman role in denying treatment to millions
infected with HIV/AIDS, the WHO is concerned about possible harm to the
Intellectual Property System. Clearly, the Washington consensus now extends to
Geneva!
CONTINUED
RELEVANCE OF ALMA ATA DECLARATION
Almost
twenty five years after the Alma Ata Declaration was issued, its relevance
assumes even greater importance. There is, today, extensive evidence that public
health has been an obvious casualty of the pursuance of neo-liberal economic
policies across the world. There is a clear contradiction between the principal
tenets of public health and neo-liberal economic theory that permeates policy
making today. The former posits that public health is “public good”,
i.e. its benefits cannot be individually appropriated or computed, but have to
be seen in the context of benefits that accrue to the public. Thus public health
outcomes are shared, and their accumulation lead to better living conditions.
Such goods never mechanically translate into visible economic determinants, viz.
income levels or rates of economic growth. Kerala, for example, has low per
capita income but its public health parameters rival those in many developed
countries. The Infant Mortality Rate in Kerala is less than a third of any other
large state in the country. But neo-liberal economic policies are loath to even
acknowledge such benefits. The current economic policies would rather view
health as a private good that is accessed by the medium of the market.
